4 Clinical Guidelines Every Hospitalist Needs to Know

Alok S. Patel, MD; Alfred P. Burger, MD


June 05, 2019

Alok S. Patel, MD: I'm Dr Alok Patel with Medscape, and I'm honored to be standing next to Dr Alfred Burger from Mount Sinai Beth Israel. We're going to talk about the top clinical guidelines every hospitalist needs to know.

Clostridium difficile Infection—Metronidazole No Longer a First-line Agent

Let's start with C diff infection. We see it all the time. It's prevalent in adults, and according to the Centers for Disease Control and Prevention, we're seeing thousands of cases a year.[1] What is the update that we all need to know about C diff?

Alfred P. Burger, MD: The C diff document from the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America[2] is very complex and detailed. It's about 50 pages long. For physicians who are taking care of patients on a daily basis, about 12 to 13 of the 30-plus points are things that we need to know.

We really need to understand that metronidazole is no longer a choice as a first-line agent for standard C diff. We should be moving to vancomycin or some of the newer agents—fidaxomicin is the one they recommend—for a 10-day course for treatment. The other changes have been around how we should treat the first, second, and third recurrence.

I recommend that physicians look at the full guidelines. There are some newer agents that are options to use, as well as things like stool transplant.

Opioid-Induced Constipation—'Laxatives, Laxatives, Laxatives'

Patel: Speaking of stool, I heard that opioid-induced constipation is another point that you mentioned in your talk. Can you give us a highlight of that?

Burger: I think the highlight in the guidelines put forward by the American Gastroenterological Association is "laxatives, laxatives, laxatives."[3] The newer agents that are directly targeted to the mu receptors are conserved second line for failure of laxatives. They discuss each specific agent and the level of evidence behind their recommendation for the use or triage of which agent to use at what time.

Patel: Right. Maybe with less narcotic use, we will see less of that problem to begin with.

Burger: I think everybody hopes for that.

Noninvasive Ventilation—When and When Not to Use It

Patel: Another topic that we talk about all the time in every hospital is noninvasive ventilator support for respiratory failure. Can you give us an overview of that?

Burger: There are great data in both COPD and CHF for its early use.[4,5,6] There are a few very clear guidance points around when to use it, and not to overuse it, but also that it should be used early.

There are about 11 other areas where it can be used, such as with chest trauma and asthma, where the data are not as conclusive but they offer some great guidance around these points.[6] And again, I think the devil is in the details and the details are really going to be found in the article. For those who are interested, I do suggest taking a look at it.

Patel: Well, we just need to be nerds about details. Don't just jump to high flow, right?

Diabetes Sliding Scale Should Not Be Your 'Go-to' Agent

Patel: And last but not least, what is the latest and greatest with diabetes and sliding scales?

Burger: Sliding-scale regimens alone are really not for everybody. We should be putting people on a basal insulin with a premeal bolus, and adjusting for those diabetics who need it and who routinely have glucose levels above 180 mg/dL while in the hospital. For sliding scale, you may use it in the first 24 hours to figure out where you're heading, but really it should not be our go-to agent.

Patel: Not our go-to agent.

C diff management, diabetes sliding scales, noninvasive ventilator support, and opioid-induced constipation—every single hospitalist in America manages one of these every day.

Dr Burger, thanks so much for chatting with us.


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